Payers (the P1) are health plans, also known as health insurance companies or carriers. They are Payers because they pay medical and pharmacy bills for the members. Payers could be commercial health plans or government sponsored plans like Medicare, Medicaid, MLTC, PDP, CHIPS, MAPD etc. The main objective of the payer is to ensure that they deliver the best possible health outcomes for the members (i.e., patients).
Payers could be broadly categorized into three levels within the United States: national, regional, and local. Government programmes such as Medicare and Medicaid set the amount they will pay to health care providers. While rising health care costs are the ultimate issue for patients, providers, and payers alike, the payer's core goals remain:
Insurance underwriting and risk management.
Aligning with health care providers to achieve the outcome goals
Competition from provider-owned payers (POPs).
Consumer education about coverage and costs, including patient pay and deductible,
Consumer education on healthcare.
Healthcare laws and compliance, including HIPAA, ACA, PHI, etc.
IT, MIS, and systems integration
Population Health Management (PHM) and Population Care Management (PCM)
Preventing Fraud, Waste and Abuse (FWA).
Provider Credentialing
Governments have limited healthcare budgets, resulting in insufficient resources to fund all the population's health care wants and needs. It is, therefore, the role of the Payers to make informed, evidence-based decisions on which treatments to fund. Technology has revolutionized the healthcare industry, and payers have had to adapt to keep up with the changes. Payers are increasingly using technology to improve their processes.
Team GHIT helps payers (P1) and their LOBs adopt and take advantage of technologies, cloud-based tools, and accelerators. Claims management systems, provider network management systems, healthcare analytics and reporting, customer relationship management (CRM) systems, fraud detection and prevention systems are examples of such enterprise systems that help improve the efficiency and quality of healthcare delivery while keeping costs down.
We are happy to set up a quick call to share our credentials and capabilities around our healthcare payer (P1) technology support and services.
